Are you ready for a new career path?
Do you want to land a more fulfilling job than the one you're in now?
Are you looking for a company that values integrity, initiative, good judgment and teamwork?
As a part of our continued growth, we are searching for the right individual to join our team!
We are looking for individuals with a strong desire to embrace and represent our unique culture founded on our Core Values of Integrity, Initiative, Good Judgment and Teamwork and our passion for changing lives through leadership development.
AmeriBen is a leader in the benefits administration industry with a strong track record for consistent double-digit growth (doubling every five years for the past 30 years). We are experiencing wonderful nationwide growth and need effective, dynamic leaders with good values to help us continue this momentum.
There's an energy and excitement here, an opportunity to work with a diverse culture while sharing a goal to improve the lives of others, as well as our own. The result is a culture of performance that's driving the health care industry forward.
If you are an RN with a passion for helping people succeed in managing their health, our position may be for you. The AmeriBen Medical Management team provides utilization management, case and disease management services to thousands of members navigating the complex world of healthcare. You have the chance to change lives with the benefits of a salaried position combined with a work-life balance!
The Utilization Review/Precertification Registered Nurse utilizes clinical experience and medical guidelines in a collaborative process to assess, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Coordinates medical services requests from providers and determines medical necessity using internal guidelines, nursing judgment and the specific requirements of the member's health plan.
Key Result Areas
- Conducts telephonic utilization review/precertification services including: prospective, concurrent and retrospective review utilizing clinical criteria guidelines, nursing judgment and physician advisor review as needed.
- Determines medical necessity and appropriateness of requested inpatient and outpatient services through review of clinical information and application of the appropriate clinical criteria guidelines.
- Assesses the member's current status, future care needs and treatment plan.
- Communicates with providers and other departments to facilitate care, transitions of care, and discharge planning.
- Identifies solutions to non-standard requests and problems.
- Identifies members for referral opportunities to integrate with other services (i.e. Case Management, Health Management).
- Works closely with providers to ensure appropriate utilization of services and effective cost management.
- Maintains appropriate documentation and records cost management.
- Maintains confidentiality of records and information.
- Maintains and reports applicable statistics regarding programs and patient services.
- Attends weekly Leadership Forum, Company View, on-site team meetings, and monthly staff metings.
- Performs all duties within the scope of licensure.